PRESCRIBING CEILINGS OF THE RANGE OF PRICES OF MEDICAL SERVICES OUTSIDE OF THE SCOPE OF COVERAGE BY THE HEALTH INSURANCE FUND AT STATE-OWNED HEALTHCARE ESTABLISHMENTS AND PROVIDING GUIDANCE ON PRICING AND PAYMENT OF COSTS OF MEDICAL SERVICES IN CERTAIN CASES

1. Scope of application:

This Circular provides for the ceilings of the range of prices of medical services outside of the scope of coverage by the health insurance fund at state-owned healthcare establishments and providing guidance on pricing and payment of costs of medical services in certain cases.

2. Subjects of application:

State-owned healthcare establishments; patients that have not yet participated in heath insurance; health insurance card holders that use medical services outside of the scope of coverage by the health insurance fund; other concerned entities and persons.

3. If patients with health insurance cards use medical services under the provisions of laws on health insurance, they may be entitled to the health insurance fund’s coverage for their medical costs in accordance with regulations in force.

4. This Circular shall not apply to medical services provided by:

a) Entities making capital contributions, mobilizing capital, entering into joint ventures or affiliations under the provisions of Article 6 of the Government’s Decree No. 85/2012/ND-CP dated October 12, 2012 on the operational and financial mechanism for state-owned healthcare establishments and implementation of prices of medical services according to the principles of provision of adequate expenditures on offsetting costs incurred and collection of accumulated revenues;

b) Healthcare service providers in the model of an enterprise which are established by loan-financed investments or investment cooperation by public service units under the Government’s Resolution No. 93/NQ-CP dated December 15, 2014 on certain health development mechanisms and policies;

c) Healthcare establishments established by investments made in a public-private partnership form as provided by the Government’s regulations on investment made in a public-private partnership form.

Ceiling prices of medical services shall be composed of the followings:

1. The ceiling prices of health check-up and examination services defined in the Appendix I hereto;

2. The ceiling prices of per-day bed services defined in the Appendix II hereto;

3. The ceiling prices of technical and laboratory services defined in the Appendix III hereto.

4. Notes on certain technical services which are ranked similar by the Ministry of Health in the Decisions of the Ministry of Health specified in the Appendix IV hereto attached.

The ceiling prices of medical services referred to in this Circular shall be set on the basis of direct costs and salaries in order to assure medical examination, care and treatment services provided to patients and implementation of medical technical services, specifically including:

1. Direct costs constituting the price of medical examination service

a) Costs of clothes, head covers, face masks, bed sheets, cushions, foam mattresses, mats, office stationery, gloves, cotton, bandages, rubbing alcohol, gauze pads, saline solutions, and other consumables, serving the medical examination needs;

b) Costs of electricity, water bills; fuel; disposal of domestic and medical wastes (in a liquid or solid form); laundry, drying, disinfection of fabrics and appliances used for examination of patients; cleaning and environmental hygiene services; sterilization and disinfection supplies, chemicals used for patient examination;

c) Costs of repair and maintenance of facilities and equipment, purchase of replacements for the following property, appliances and instruments: air conditioners, computer sets, printers, dehumidifiers, fans, desks, chairs, beds, cabinets, lights and other toolkits necessary for patient examination activities.

2. Direct costs constituting the price of the per-day bed service

a) Costs of clothes, head covers, face masks, blankets, bed sheets, cushions, foam mattresses, mosquito nets, mats; office stationery; gloves used in patient examination, injection and infusion, cotton, bandages, alcohol, gauze pads, sterile saline solutions and other consumables for daily uses in medical care and treatment activities (including costs of change of wound covering bandages, post-surgery dressings for inpatients, except in case where patients are entitled to payments exceeding the per-day bed price specified in clause 4 and 5 of Article 7 herein); electrodes, ECG cables, blood pressure measuring armbands and SPO2 sensor cables used in patient monitoring systems at emergency care and intensive care beds.

Costs of medicines, blood, intravenous fluids and other medical supplies (except for the aforesaid medical supplies); syringes, hypodermic needles, dispensing needles used in injection, infusion and feeding; catheters, connecting tubes, extension tubes used in electric syringe infusion pumps, infusion pumps used for injection and infusion activities; oxygen supplies, oxygen nasal cannulas, oxygen masks (except in case where breathing equipment is indicated for patients), which have not yet been listed in the structure of prices of treatment beds, shall be paid based on patients’ actual uses.

b) Costs referred to in point b and c of clause 1 of this Article that are paid for care and treatment of patients to meet medical requirements.

3. Direct costs making up the prices of medical services

a) Costs of clothes, head covers, face masks, bed sheets, cushions, foam mattresses, mats, fabrics; office supplies; medicines, intravenous fluids, chemicals, consumables and replacement supplies used during the period of implementation of medical services and techniques;

b) Costs stipulated in point b and c of clause 1 of this Article which are paid for implementation of technical medical services to meet the medical requirements.

4. Costs for wages and salaries which constitute the prices of medical examination, per-day beds and other technical medical services shall comprise the followings:

a) Salaries specific to pay ranks, positions, allowances and contributions under the state policies applied to public service units and base pay rates prescribed in the Government's Decree No.72/2018/ND-CP dated May 15, 2018 on base pay rates of officials, public servants, public employees and members of armed forces;

b) Regular task allowances or allowances paid in case of operations or surgeries under the Prime Minister’s Decision No. 73/2011/QD-TTg dated December 28, 2011 on particular policies of subsidies paid to officials, public servants and public employees working for public healthcare establishments, and allowances paid for prevention and control of epidemics.

5. Costs for wages or salaries constituting the prices of services referred to in clause 4 of this Article shall not include state budget-funded expenses stipulated in the following documents:

a) Government’s Decree No. 64/2009/ND-CP dated July 30, 2009 on policies granted to public officials and public servants performing healthcare tasks in areas with extremely underprivileged socio-economic conditions;

a) Government’s Decree No. 116/2010/ND-CP dated December 24, 2010 on policies granted to public officials and public servants and salaried persons working as members of armed forces in areas with extremely underprivileged socio-economic conditions;

c) Prime Minister’s Decision No. 46/2009/QD-TTg dated March 31, 2009 prescribing particular policies of allowances paid to public officials and public servants working for Huu Nghi hospital, Thong Nhat hospital, Hospital C – Da Nang affiliated to the Ministry of Health, Central Health Protection Center 1, 2, 2B, 3 and 5, Department A11 of Military Central Hospital 108 and Department A11 of Military Hospital of Traditional Medicine (hereinafter referred to as Decision No. 46/2009/QD-TTg) and the Prime Minister’s Decision No. 20/2015/QD-TTg dated June 18, 2015 on amendments and supplements to certain articles of the Decision No. 46/2009/QD-TTg;

d) Point a of clause 8 of Article 6 of the Government’s Decree No. 204/2004/ND-CP dated December 14, 2004 on policies of wages and salaries paid to public officials, public servants, public employees or members of armed forces, and the Government's Decree No. 76/2009/ND-CP dated September 15, 2009 on amendments and supplements to certain articles of the Government’s Decree No. 204/2004/ND-CP dated December 14, 2004 on policies of wages or salaries paid to public officials, public servants, public employees and members of armed forces.

1. Competent authorities stated in clause 2 and 3 of this Article shall be accorded authority to grant the decision on specific prices of medical services at healthcare establishments within their jurisdiction which are not in excess of the ceilings of the range of prices of medical services referred to herein.

2. Provincial People’s Councils shall be accorded authority to grant the decision on specific prices of medical services provided by healthcare establishments under their remit and grant the decision on specific prices or impose prices of medical services in certain cases according to the following principles:

a) Hospitals with medical beds, provincial medical centers providing medical examination and treatment services; district-level medical centers providing both disease prevention and medical examination or treatment which have already been ranked, shall adopt the prices applied to hospitals of similar rank;

b) Healthcare establishments which have not yet been ranked shall adopt the prices applied to hospitals ranked IV;

c) Regarding regional general clinics:

- If they are licensed or fall into cases stipulated in clause 1 of Article 11 of the Government’s Decree No. 155/2018/ND-CP dated November 12, 2018 on amendments and supplements to certain regulations related to investment and business conditions within the remit of the Ministry of Health, the prices applied to rank-IV hospitals shall be adopted;

- If they only provide emergency care, outpatient medical examination and treatment services, the prices applied to rank-IV hospitals shall be adopted. If they are subject to the decision of the Department of Health on whether they have inpatient beds, the price shall be equal to 50% of the price of a per-day bed at class-3 departments of rank-IV hospitals. The maximum number of days during which payments may be made for medical beds shall be 03 days/patient/treatment period. Payment of medical examination costs will not be required if payment of inpatient bed costs has been made.

d) Healthcare stations at communes, wards or towns

- Medical examination prices shall adopt those quoted by commune-level health stations. Prices of technical services shall be 70% of the prices of medical services referred to in the Appendix III;

- If health stations are subject to the decision of the Department of Health on whether they have inpatient beds, the price shall be equal to 50% of the price of a per-day bed at class-3 departments of rank-IV hospitals.

3. The Minister of Health shall be accorded authority to decide on the specific prices of medical examination and treatment services provided by healthcare establishments affiliated to the Ministry of Health and special-rank or first-rank hospitals of Ministries and central regulatory bodies. As for the rest of healthcare establishments affiliated to Ministries and central regulatory bodies, pricing of medical examination and treatment services shall be subject to the following regulations:

a) Healthcare stations of entities or organizations, military-civilian healthcare stations, military-civilian healthcare clinics shall adopt the prices of medical examination and treatment services as applied at healthcare stations of communes, wards and towns of local jurisdictions.

b) Military-civilian infirmaries shall adopt the prices of medical examination and treatment services as applied to regional general clinics at local jurisdictions.

c) Rank-II, III and IV hospitals (including military-civilian hospitals) shall adopt the prices of medical services as applied to healthcare establishments of same rank at local jurisdictions.

d) Other healthcare establishments shall adopt the prices of medical services as applied to rank-IV healthcare establishments at local jurisdictions.

4. If healthcare establishments affiliated to Ministries or central regulatory bodies render technical services which have not yet specified in regulations on prices of medical services at local jurisdictions, healthcare establishments must formulate the pricing plan filed to the Ministry of Health for its consideration and grant of its decision.

5. If the ceiling prices of new technical services referred to in clause 1 and 2 of Article 69 in the Law on Medical Examination and Treatment and other technical services (except those ranked the same in terms of technical issues and service costs) have not yet been regulated,

a) Healthcare establishments must calculate and recommend prices to competent authorities as provided in Article 4 hereof in order to obtain the decision on temporary prices;

b) Every 6 months (on June 30 and December 31 every year), entities and local jurisdictions must submit general reports to the Ministry of Health for its consideration and issuance of regulations on supplementation of ceiling prices after obtaining consent from the Ministry of Finance.

c) Pricing procedures and documentation on pricing plans shall be subject to provisions of laws on prices.

In certain cases, the number of times of use of and prices of medical examination services shall be determined as follows:

1. If a patient comes to an outpatient department to receive his/her health check-up and then is advised to be hospitalized for inpatient treatment services to meet medical requirements, payment of medical examination fees shall be subject to provisions laid down in clause 2 of this Article. In case where that patient does not register at the outpatient department but receives medical examination and inpatient treatment services at other clinical departments according to medical requirements, payment of medical examination fees shall not be covered.

2. With respect to healthcare establishments having specialized exam rooms in clinical departments, if a patient registers at outpatient departments and receives medical examination at these specialized exam rooms, he/she shall be considered as using medical examination services provided by outpatient departments. Calculation of costs and the number of times of use of medical examination services shall follow instructions given in clause 3 of this Article.

3. At the same time of use of medical examination services at a healthcare establishment (maybe on the same day or for objective reasons or subject to medical requirements, medical examination services have not yet been finished in the first day and must be continued in the next day), if a patient needs to come to another department after visiting the first department, the price of the second or later time of use of medical examination services shall be 30% of the price of the single time of use of medical examination services and the maximum amount of payment of medical examination costs shall not be 2 times greater than the price of the single time of use of medical examination services.

4. If a patient visits a healthcare establishment where he/she has used medical examination services and received medicines, but then finds abnormal signs and immediately returns to that healthcare establishment within the same day to check his/her health again, this use of medical examination services shall be considered as the second or later time of use of medical examination services within the same day. Payment shall be made according to instructions given in clause 3 of this Article;

1. Determination of the number of days of use of inpatient beds for payment of medical bed costs shall be regulated as follows:

a) The number of days of use of inpatient treatment services is defined by the day of dehospitalization minus (-) the day of hospitalization plus (+) 1. This formula shall be applied in the following cases:

- Pathological conditions of a seriously-ill patient currently using inpatient treatment services have not been alleviated, he/she is dead or faces serious health problems and his/her family asks for permission to take him/her home or refer to another higher-level healthcare establishment;

- A patient has been successfully cured by a higher-level healthcare establishment over the emergency care stage, but still needs to continue to use inpatient care services be referring him/her to another lower- or similar-level healthcare establishment;

b) The number of days of use of inpatient care services is defined by the day of dehospitalization minus (-) the day of hospitalization. This formula shall be applied to other cases.

c) If a patient hospitalized and dehospitalized in the same day (or hospitalized in the previous day and dehospitalized in the following day) is treated from more than 04 hours to under 24 hours, this treatment shall be considered as lasting 01 day. If that patient is received in the emergency care department without registering at the outpatient department, and has the emergency care and treatment duration of 04 hours or less (even in the case of dehospitalization, hospitalization, referral or death), he/she shall be entitled to payments for medical examination services, medicines, medical supplies and other technical services, but shall not be entitled to coverage of fees for his/her per-day emergency bed.

d) If a patient is hospitalized and dehospitalized in the same day and is treated for the maximum duration of 04 hours, he/she shall be entitled to payments for medical examination services, medicines, medical supplies and other technical services that he/she has used, but shall not be entitled to coverage of fees for his/her per-day emergency bed.

2. If a patient is referred to 02 departments in the same day, his/her treatment shall be considered as lasting a half of day. If that patient is referred to 03 departments or more, the price of per-day bed in that day shall be determined by the arithmetic mean of per-day bed fees arising at the department where he/she is treated for more than 04 hours and is charged at the highest price of per-day bed and at the department where he/she is treated for more than 04 hours and is charged at the lowest price of per-day bed.

3. The price of a per-day bed provided by the surgery or burns department shall be valid for the duration of 10 days or fewer after each surgery. From the 11^th day onwards, the price of a per-day bed shall be the price of per-day internal treatment bed at respective departments prescribed in section 3 of the Appendix II hereto.

4. The price of per-day bed shall be applicable to only 01 patient per 01 bed. In case where, at the same time, sharing a bed between 02 patients is required, a half price of per-day bed shall be applied. If a bed is shared by 03 patients or more, the one-third price of bed per the number of treatment days shall be applied.

5. The price of medical bed for treatment at the intensive care unit shall be applied:

a) to special-rank, rank-I or rank-II hospitals with intensive care departments, antitoxic departments or centers, intensive care – antitoxic departments that fully meet operational requirements under the Decision No. 01/2008/QD-BYT dated January 21, 2008 of the Minister of Health on issuance of emergency treatment, intensive care and antitoxic regulations (hereinafter referred to as Decision No. 01/2008/QD-BYT).

b) if healthcare establishments have not had intensive care departments but their emergency departments or anesthesiology and intensive care departments have certain beds for intensive treatment, and medical beds for care after special surgeries, all of which meet requirements concerning equipment installed at these beds as provided in the Decision No. 01/2008/QD-BYT.

c) if patients using these beds suffer from pathological conditions that need care, treatment and monitoring according to emergency care, intensive care and antitoxic regulations. In cases other than those mentioned above, the price of emergency treatment bed and other bed referred to in Appendix II hereto shall be applied.

6. Clinical treatment departments with emergency treatment beds (for example, the pediatrics department with pediatric intensive care beds, the neonatology or immature infant intensive care department) shall be allowed to apply the price of intensive care bed as stipulated in the service no.2 of the Appendix II hereto.

7. Rank-III, rank-IV hospitals or those not yet ranked but obtaining the competent authority’s approval for performing special surgeries may apply the highest price of surgical treatment bed at hospitals where such medical services are implemented.

Example: At Hospital A obtaining approval for performing special surgeries, If it is a rank-III hospital, it may be entitled to apply the price of the bed used after the class-I surgery performed at rank-III hospitals; if it is ranked IV or not yet ranked, it may apply the price of the price of the bed used after the class-I surgery performed at rank-IV hospitals.

8. If a surgery is classified in different manners by departments (except pediatrics department) in the Circular No. 50/2014/TT-BYT dated December 26, 2014 of the Minister of Health prescribing classification of surgeries, operations and manning requirements in each medical surgery or operation (hereinafter referred to as Circular No.50), the price of per-day bed for surgical or burn treatment classified as the lowest-level surgery shall be applied.

9. Surgeries which are ranked by the Ministry of Health equal to one of surgeries specified in this Circular, but which are classified into different surgeries by specific departments as provided in the Circular No. 50, may apply the price of per-day bed for surgical or burn treatment according to the classification of these surgeries as provided in the Circular No. 50.

10. Surgeries which have not yet been classified under the provisions of the Circular No. 50 may apply the price of class-4 bed for surgical treatment at equivalent-rank hospitals.

11. Rank-I traditional medicine hospitals affiliated to the Ministry of Health may apply the prices of per-day beds at respective departments which are the same as those at rank-I hospitals, and shall not be allowed to apply the prices of beds at specialized hospitals affiliated to the Ministry of Health in Hanoi and Ho Chi Minh city.

12. Departments of traditional medicine hospitals (except those specified in clause 11 of this Article) and medical care and rehabilitation hospitals:

a) ICU beds shall be priced as per clause 5 of this Article;

b) Emergency intensive care beds shall be priced as per clause 6 of this Article;

c) Prices of beds for patients treated at oncology and pediatrics departments shall be the same as the prices of class-1 per-day beds for internal treatment;

d) Patients treated for one of the diseases, including spinal cord trauma, cerebrovascular accident or traumatic brain injury, may be charged at the price of class-2 per-day bed for internal medicine treatment;

dd) Patients treated at other departments may be charged at the prices of class-3 per-day beds for internal treatment.

13. Healthcare establishments with joint departments may apply the prices of per-day beds for internal medicine treatment of the lowest-level department amongst departments in relation to ranks of hospitals.

14. If a patient rests on stretchers or foldable beds, the price of bed shall be 50% of the price of bed specific to departments as provided in Appendix II hereto.

1. Medical technical services shall be priced in the following order:

a) Specific services of which prices have been prescribed in appendices to this Circular shall be priced in accordance with regulations in force.

b) Medical technical services of which prices have been regulated in appendices to this Circular, but which are ranked equal in terms of technical contents and costs, may apply the prices of services ranked equal by the Ministry of Health in terms of technical contents and costs.

c) If there is any overlap between different departments, medical technical services performed at a department shall apply the prices of services rendered at that department.

2. Fees for medical technical services present in the list of medical technical services approved by competent authorities (Ministries, central regulatory bodies with respect to healthcare establishments under their management, Departments of Health with respect to units under the management of local jurisdictions) (except medical care services of which costs have already been included in the cost of per-day beds, services deemed as a technical stage of which costs are included in costs of other services), but which have not been priced yet; indicated medical technical services which are not continued for reasons of pathological changes or physical conditions of patients, shall be paid based on the actual quantity of medicines and medical supplies used for these patients and at the purchase prices prescribed by lawsoft.

3. If multiple medical actions are taken in the same surgery, fees for such actions shall be paid at the price of the most complicated surgery which is highest. Meanwhile, payments for other medical technical services arising outside the aforesaid surgical procedures shall be as follows:

a) Equal to 50% of the prices of additional surgeries if these additional surgeries are still performed by the same surgical team;

b) Equal to 80% of the prices of additional surgeries if these additional surgeries are performed by another substitute surgical team;

c) If additional services are medical procedures, 80% of the prices of these additional services shall be paid.

4. Price of the medical technical service called “Changing a medical bandage or surgical dressing at the length of ≤15 cm” shall be applied to an inpatient only if his/her wound or incision is infected; a skin tissue dissection or open wound at the skin area of more than 6 cm² is impregnated with bodily fluid or blood; a wound is covered with a gauze pad; a large amount of bodily fluids flow at the contact point between an effusion tube and a wound; multiple traumas or incisions appear; he/she has undergone a surgery with at least two incisions; that price shall not be applied to changing bandages with respect to an endoscopic surgery, change of a common incision dressing, wound bandage or umbilical bandage.

5. Price of the medical service called “Changing a surgical incision dressing at the length ranging from more than 15 cm to 30 cm” for an inpatient shall be applied:

a) In case of infected surgical incision, gastrointestinal, bile duct or urinary tract leak;

b) In case a post-surgery incision is infected (peritoneal membrane infection, bone infection or abscess), an incision made after intestinal tube, genitourinary or abdominal ascite;

c) In case of a surgery making at least two incisions;

d) In case of an obstetric surgery which is performed no more than 03 times.

6. Prices of immunocompatibility tests performed at temperature of 37ºC and using anti-globulin serum (indirect test Coombs) for blood transfusion shall be the same as the price of the medical service called “Immunocompatibility reaction using anti-human globulin serum” numbered 1340 or 1341 in the Appendix III.

1. The state budget shall provide allocations under decentralized authority for:

a) Expenses prescribed in clause 5 of Article 3 hereof;

b) The State budget's allocations for reform of pay policies in accordance with the Government’s applicable regulations on wages and salaries paid to officials, public servants and employees and members of armed forces.

c) In case the funding source of a healthcare establishment does not cover regular costs, it shall be classified by a competent authority as a public service unit covering a part of regular costs on its own or a public service unit of which regular costs are covered by the state.

2. Responsibilities of the Ministry of Health:

a) Authorize the Planning – Finance Department to preside over and cooperate with relevant units in implementation, examination, preliminary or final review of implementation of this Circular across the nation;

b) Agree with the Ministry of Finance to consider and adjust ceilings of the range of prices of medical examination and treatment services referred to in appendices hereto when supplementing pricing elements according to the roadmap, adjust economic-technical norms or costs of changed pricing elements.

3. Responsibilities of the Departments of Health:

a) Preside over and agree with the Service of Finance on preparing reports for submission to provincial People’s Committees that then present them to provincial People’s Councils for their consideration before issuing the decision on service prices and effecting time with respect to healthcare establishments under local jurisdiction.

b) Preside over and cooperate with relevant units in implementation, inspection, oversight, preliminary review and final review of implementation of this Circular within their remit.

c) Direct healthcare establishments under local jurisdiction to continue to strictly implement regulations on medical practices, and uniformly implement measures to improve service quality.

d) Report to competent authorities to approve the number of beds, decide the number of employees working for healthcare establishments under local jurisdiction in order for these healthcare establishments to have the adequate number of beds and employees to meet demands and improve the quality of medical examination and treatment services provided for the public.

4. Responsibilities of healthcare establishments:

a) Use the amount of funds equal to costs of care and maintenance of equipment, purchase for replacement of tools and instruments of which costs have already constituted the prices of medical examination and per-day bed services (those of special-rank, rank-I and rank-II hospitals equaling 5% of the predetermined price; those of rank-III, rank-IV or unclassified hospitals equaling to 3% of the predetermined price) for repair, upgradation and expansion of medical examination zones and medical treatment departments; costs of purchase for supplementation and replacement of desks, chairs, beds, cabinets, armchairs, air conditioners, fans, warming lamps, warming fans, computer sets, toolkits for medical general or specialized examination; blankets, bed sheets, cushions, foam mattresses and mats,... for satisfying medical conditions and requirements concerning patient hygiene, safety and improvement of quality of patient services.

b) Strictly comply with regulations on the healthcare practices, especially indications of advising patients to use inpatient treatment services; referrals and indications of use of medical services, medicines and medical supplies in accordance with regulations in force.

In case where reference documents mentioned in this Decree are replaced or revised, the substitute or revised document shall prevail.

1. This Circular shall enter into force from January 15, 2019.

2. The following instruments shall become invalid from January 15, 2019:

a) Circular No. 02/2017/TT-BYT dated March 15, 2017 of the Ministry of Health prescribing the ceilings of the range of prices of medical services outside of the scope of coverage by the health insurance fund at state-owned healthcare establishments and providing guidance on pricing and payment of costs of medical services in certain cases;

b) Circular No. 44/2017/TT-BYT dated November 16, 2017 of the Ministry of Health on amendments to the Circular No. 02/2017/TT-BYT dated March 15, 2017 of the Ministry of Health prescribing the ceilings of the range of prices of medical services outside of the scope of coverage by the health insurance fund at state-owned healthcare establishments and providing guidance on pricing and payment of costs of medical services in certain cases.

While expecting competent authorities to make their decision on prices of medical examination and treatment services under the provisions of this Circular, healthcare establishments shall be entitled to continue to apply prescribed prices until such decision is made.

In the course of implementation of this Circular, should there be any query or difficulty, involved entities and local jurisdictions shall be required to inform the Ministry of Health in writing to seek its assessment and possible solutions./.